23 minute read
The Longest Delay
The Longest
Delay
By Lt. Stephen Allum
Ihad completed the best possible JO tour with the VS-24 Scouts: two combat cruises filled with moonless, overcast night traps, unforgettable port-call memories, and other squadron functions to reminisce on later in life. However, my last encounter with the “War Hoover” was anything but enjoyable.
It was late July 2003, and I was scheduled to fly with a good friend—call sign “Mr. Gadget” for this article. Our typical “routine, good deal” flight was scheduled to last only a couple of hours, and then return to NAS Jacksonville. What could go wrong? It was morning and VFR. We were two senior JOs with plenty of S-3 experience, and squadron NATOPS instructors. The first part of the flight went as planned, with no problems or surprises. Then we encountered the dangerous part of the flight: the airnav home.
When we reached our final cruising altitude of FL190, the No. 1 bleed-leak light came on. This light means an over-temperature condition in excess of 127 degrees Celsius in the vicinity of an applicable bleed line. This condition generally is caused by a broken or cracked line, seal or fire in the environmental-control system (ECS) compartment. We secured the No. 1 bleed-air switch according to NATOPS. But, the second we closed the No. 1 bleed-air system, the No. 2 bleed-leak and APU bleed-leak lights illuminated, while smoke entered the cockpit. We continued with the remaining immediate-action items of donning our O2 masks and securing the No. 2 bleed-air switch.
While watching the clock, waiting for the lights to extinguish and smoke to clear, I remembered this warning in NATOPS: “Simultaneous illumination of the No. 1 and No. 2 bleed-leak lights may indicate an ECS compartment fire. In this event, the crew should be alert for secondary indications that would confirm a fire, such as smoke or fumes in the cockpit.” Mr. Gadget reached for his PCL, and then the fun really began.
Waiting for at least one of the three bleedleak lights to extinguish, the No. 1 hyd-level light illuminated (which meant less than two gallons of fluid remained in the No. 1 system). Smoke continued to fill the cockpit, so Mr. Gadget and I began to perform more boldface procedures for smoke or fumes removal, including securing the air conditioning, opening the auxiliary vent, and dumping cabin pressure. The results were limited, and the smoke remained. We had reached a four-minute wait in the PCL
on the bleed-leak procedure for the lights to extinguish.
Then I made the call I thought I never would have to say, “Atlanta center…Scout 7…declaring an emergency…we’ve got some bleed problems and smoke in the cockpit.”
I moved the transponder dial to “EMER,” and Mr. Gadget dialed in 7700. Then the master-caution panel illuminated the cockpit with more “attention-getting” lights, including: wing unlock, speedbrake caution, trailing-edge flaps locked, and the transition light in the landing-gear handle (handle still in the up position). While looking down at the master-caution panel—I was reminded of Chevy Chase’s house in “Christmas Vacation”—I knew we were in serious trouble. I saw the ECS-fire light. Center did an outstanding job vectoring and descending us to our nearest divert and satisfying all our requests, but, unfortunately, the situation only got worse.
While in the descent to a lower altitude, we saw the No. 2 hydraulic gauge decrease to zero, followed shortly by more stick pressure on the controls to maintain straight and level. I performed the aircraft-failureto-respond-to-control-inputs boldface. But, more smoke began to enter the cockpit, and the jet went uncommanded into its emergency-flight-control system (EFCS). The EFCS is an automatic changeover that takes place when total hydraulic pressure drops below 800 psi. It is completely mechanical and, with the aid of the independent trim system, is like driving your car with no power steering.
This was not our day. I told the warrior sitting beside me, “We’re in EFCS, and I’m securing the hydraulic servos.”
The jet still was controllable, but we avoided big angle of banks and high airspeeds. Center assisted us with a long straight-in, so we could lose altitude without using speedbrakes, maintain control, and finish required checks for emergency extension of gear and flaps. As if we weren’t busy enough, our navigation and several instrument displays quit working; then, our radios and ICS went silent. Mr. Gadget yelled me a vector to our intended point of landing (with his hand-held GPS on his knee), but we didn’t make it.
A few moments later, the smoke became extremely thick in the cockpit, and then the nightmare occurred. The control stick lost all stiffness and went completely limp in all directions, while the aircraft remained in straight and level flight. The stick had no inputs to any of the flight controls.
You have got to be kidding me! I looked up and saw that the hydraulic servos remained in the off position and that we were passing 10,000 feet. We had a failure of the flight controls while flying in EFCS? Where is that EP in the PCL? What else could we do to extinguish this fire and save the aircraft?
Realizing we were descending, and the jet relatively was straight and level at a fairly slow and safe airspeed,
in the cockpit, and then the nightmare occurred.
I looked at my COTAC, while moving the control stick in all directions (the jet remained level), and just shook my head “no.” He signaled with his arm—a signal I barely saw through the smoke—for the ejection.
I waited for his left arm to get in position, and then I leaned back, pulled the ejection handle, and had the longest .96-second delay in my life.
Time compression had us believing our seats had failed. Now what? Would I have to blow the canopies, use the emergency-restraint release, and jump out, pulling my D-ring? I then saw an orange flash, heard a loud bang, and got propelled out of the aircraft. After being beaten and tossed around in the airstream, everything suddenly went completely quiet and in slow motion.
I looked up and saw a good chute. I inflated my lobes, and then looked down—I saw trees. “Oh, this is going to hurt,” I thought.
I kept my visor down, mask and gloves on, and secured my seat pan. Looking to my right, I saw Mr. Gadget in his chute with his hands up. Wanting to land with him, I engaged the steering risers, pulled down on the right handle, and began to travel toward him. Unfortunately, the wind at altitude had me pass behind him and to his right just before hitting the ground. As I looked up at the horizon, I heard tree branches snapping, and I felt a few tugs to the left and right. My feet hit, I released my Koch fittings, and rolled on the ground to a stop.
The flight gear and patches came off, while I reached for the beacon in the seat pan. “Wait,” I thought, “I’m in the U.S. not in combat.”
I pulled out the “triple beacon radio” (unfortunately, I didn’t triangulate our position) and got in comms with Mr. Gadget. Thank God, he was all right. I grabbed my whistle and blew in short bursts to help guide him to my position. He soon walked up with only minor abrasions on his face and arms.
Once again, Mr. Gadget came through. He reached in his pocket, pulled out his cellphone, acquired a signal, and called the squadron.
We had gone down in Georgia’s thick pine forest. We gathered our gear, walked to higher ground to a more open area for visual rescue, and waited for a helicopter.
Throughout the next four hours, we lit several smoke and flare signals, but the smoke dissipated each time in the trees before rising high enough to be effective. I referenced north with the compass, drank water, and got in touch with several civilian aircraft on the radio, but they soon got out of range. Mr. Gadget, however, was able to reach the Georgia State Patrol rescue helicopter on the radio while I got more smokes ready. It was the orange and white parachute stretched over trees and shrubs, though, that acquired their sight. What a relief! They vectored a search team through the woods to us, then rushed us to the nearest hospital.
The total time from declaring the emergency with ATC to our ejection was only about four minutes. A lot of NATOPS procedures were performed in the jet and crew coordination was essential. A former skipper explained it best this way, “I have an opportunity for self and mishap examination that will allow me to formulate my thoughts on leadership. Use this as a learning experience to teach others. Realize sometimes you can do everything right and still lose the jet.” Yet, another friend (in his own caring ways) explained that I only needed a couple of more jumps to acquire my jump wings. Hooyah!
Everyone did their part to make sure we returned to our friends and families, and we are forever grateful. But, special thanks go out to HS-3 for flying us back home. Even off the boat, they still provide top-notch search and rescue.
Lt. Allum flew with VS-24 at the time of the mishap. He now flies with VAQ-129.
AMB Analysis By Lt. Jon Styers
Postflight analysis by the AMB revealed that a major fire occurred in the ECS compartment. In the immediate vicinity of the heat-source center are various wiring harnesses, hydraulic lines, bleed-air ducting, and an APU fuel line. As the fire grew, damage spread forward and possibly into the aircraft tunnel. Further investigation detected a hydraulic leak, which could have been atomized under pressure, resulting in a mist that can be ignited at temperatures well below its flash point. The atomized fluid was ignited by heat from the hot No. 1 bleed-air duct, resulting in an uncontrollable fire in the ECS compartment.
Lt. Styers was the VS-24 aviation safety officer. He now flies with VT-10.
Crew Resource Management and Real-Life Incidents
By Cdr. Bob Hahn and LCdr. Deborah White
Every issue, Approach runs stories in which aviators make CRM errors. These stories have comparatively happy endings. Some real-life incidents don’t end that way. Here are brief descriptions of two of them.
A tacair pilot was part of a 4 v 4 Air Intercept Control flight at night. He was unable to rendezvous after being airborne for just eight minutes. He also made atypical and nonstandard radio calls. Four minutes later, he said he felt ill, so he remained on CAP during the tactical part of the flight, after which the flight leader rejoined with him. The Hornet pilot quickly became incapacitated and crashed into the ocean without trying to eject.
He had been feeling ill before the flight but hadn’t told anyone. Although he was above 10,000 feet for 22 minutes, he wasn’t wearing his mask during the join up. After flight lead had joined up, the pilot started a gradual climb, then nosed over. Flight lead called, “Wake up! I think you are hypoxic” and “Get your nose down.”
Apparently, cabin pressure had failed; the pilot was hypoxic. There were a few examples of good CRM during the flight: He mentioned he felt ill, he opted not to continue the tactical part of the flight, and flight lead asked about hypoxia. Nevertheless, myriad CRM breakdowns and other errors proved fatal.
The second mishap involved Dash 2 of a helicopter section on an NVG simulated troop insert into an unprepared landing zone. It was the squadron’s first NVG desert mission since returning from deployment in Japan. The helo pilot had 570 hours in model. An instructor, with 2,450 hours in model, was the pilot in command but not at the controls. The pilot didn’t maintain the designated 15-second interval from the lead aircraft. He was unable to perform a no-hover landing, stirring up dust, and he couldn’t see the ground at 20 feet. During an improper waveoff, the left skid hit the edge of a gully and the helo crashed.
Before this flight, because they were in a hurry, they hadn’t done their NATOPS crew-coordination brief. The instructor had told the pilot that he would speak up if anything was wrong: In other words, silence equaled consent. They didn’t discuss brownout landings and wave-off procedures.
Again, there were a few examples of good CRM. Communication during parts of the brief was good, the pilot announced when he had lost sight, and the crew chief made two calls for power. However, again, numerous CRM errors proved impossible to overcome. Waveoff procedures were delayed. The instructor didn’t adequately back up the pilot, and the pilot never asked for help.
Statistics continue to show that human error is the largest contributor to mishaps—approximately 90 percent. An analysis of recent Class A mishaps identified poor decisions, miscommunication, degradation in situational awareness, inadequate mission analysis, and lack of assertiveness on the part of crew members as just a few of the failures that helped cause these events.
We place great emphasis on NATOPS ground and flight-training programs, instrument ground-school tests and flight evaluations, EP exams, tactics and limitations quizzes. Yet, by and large, we don’t put equal emphasis on the human factors skills that tie these aviationknowledge bases together and put them into practice.
We must improve the employment of CRM skills in the brief, through all phases of flight, and into the debrief. We must fully exploit CRM training and ingrain CRM in every simulator and every flight. CRM must receive the same level of emphasis as our NATOPS, instrument and tactics training programs.
Practicing CRM maximizes mission effectiveness and minimizes aircrew preventable errors. It also optimizes ORM by embedding and emphasizing it in the skill sets of mission analysis and decision making. The Safety Center is currently working with CNAF to revitalize the current CRM training program. Every pilot, NFO, and aircrewman in the fleet can help by revisiting and reemphasizing our CRM programs.
Cdr. Hahn directs the USN/USMC CRM Program and the School of Aviation Safety, Naval Aviation Schools Command. LCdr. White is an aeromedical psychologist at the Naval Safety Center.
Situational Awareness Assertiveness Decision Making Communication Leadership Adaptability/Flexibility Mission Analysis Beyond Limits
CRM Contacts:
CRM Instructional Model Manager NASC Pensacola, Fla. (850) 452-2088 (DSN 922) https://wwwnt.cnet.navy.mil/crm/
LCdr. Deborah White, Naval Safety Center (757) 444-3520, Ext.7231 (DSN 564) deborah.j.white@navy.mil
By Capt. David de Carion, USMC
We only had a few weeks left in our six-month deployment to Iwakuni, Japan, and we were enjoying a relatively nice—for Iwakuni—Friday afternoon. The maintenance department was catching up and getting the jets ready for our departure, and we needed a Pro A on aircraft 7.
My weapon-system officer (WSO), “Gary,” and I briefed, walked, and started the A card. We took off in our Hornet and headed to the Lima area, about 20 minutes out. The card went smoothly, all the way until the 15,000-foot checks—which thankfully since have been deleted.
We shut off the left engine, did our checks, and got it restarted. We shut off the right engine, did the checks, but, when it came time to restart, nothing happened. The rpm’s momentarily started to increase, but then they dropped to zero—great. I turned us toward the area’s exit point, started to climb, cranked the right again, and still nothing. Gary broke out the book, and I tried a third
time to get the engine to turn over—still nothing.
We decided to try a windmill start. At 17,000 feet, I put the left throttle to mil and nosed it over. At 14,000 feet, we got a flicker on the rpm’s, and, at 9,000 feet, we had 15 percent—enough to bring the throttle to idle. Finally, at 5,000 feet and 420 knots, three things happened: The bingo bug went off, we got an FCS X, and the right engine came back on-line. Gary reset the bingo bug, I reset the FCS, and we climbed to go home.
I said, “Well, I’ve had enough fun for one day, how about you?”
He replied, “Yeah, that’s about enough excitement for me.” Little did we know.
We headed back to the field, disappointed we weren’t bringing back an “up” jet but glad we didn’t have to declare an emergency. As we came out of the break, tower told us to check our gear; we were cleared to land. I dropped the gear, but, just when Gary was about to answer, we looked down and saw the right main didn’t indicate down. Then the light in the gear handle and the gear-warning tone came on.
“You have got to be (kidding) me,” Gary said. I agreed.
We told tower we only showed two gear down. They asked if we wanted to do a flyby so they could check, which we did. Tower said that not only was the right main not down and locked, it wasn’t even out of the airplane—great.
We requested a climb into the delta pattern, went to half flaps, and checked our gas. We had 2,800 pounds of fuel, so we had some time. Gary already had the book out from our restart adventure, so he began to look up the procedure. I told tower we were troubleshooting but did not yet want to declare an emergency. We also told base we showed one unsafe gear, and we were going through the procedure in the delta pattern. They asked if we needed anything; we replied, “No, not yet.”
Gary and I decided he’d verbally go through a few steps of the procedure and that I’d tell him what I was doing as I did it.
After two trips around the delta pattern, we had completed the unsafe-gear procedure, accelerated, decelerated, yawed, and pulled as many Gs as we could get out of a dirty Hornet going 150 to 200 knots. The gear didn’t budge. To add to our annoyance, we kept getting an FCS X in one of the channels, which reset every time. We decided to continue resetting it, unless we were in the middle of doing something else but then later reset it.
Base came back and asked how it was going, and we gave them the update. We still had about 1,900 pounds left, so we again ran through the procedure, but, this time, base walked us through it from the big book. We decided to declare an emergency with tower, who already had notified the crash crew and had arranged to rig the arresting gear.
We completed the unsafe-gear procedure a second time, punctuated by the statement, “Well, that’s the end of the checklist.”
In earlier training sessions, our ASO had done a superb job informing us of recent Navy and Marine Corps fatalities with off-runway landings; we were aware of what could happen.
We knew it would have to be a two-gear landing, and it was going to turn out either really well or really bad.
We were down to about 1,300 pounds when base suggested we do a touch-and-go on the good gear to knock down the bad gear. Gary and I came up with a plan, told the tower what we were doing, set full flaps, did our new version of a landing checklist, and came in for a touch-andgo. I told him if anything started to go wrong, or if either of us didn’t like where it was going, I would get us up and out of there as quickly as possible.
We did a min-sink-rate approach, and I kept up the power to give the control surfaces more authority. As the left wheel touched down, I held off the right tank (we were double bubble) with aileron. We rolled for about 1,500 feet and took off again. Our right main still showed unsafe, which tower confirmed. I did, however, have a better feeling of how the jet was going to
We had run out of time and gas,
behave on just one wheel.
We had run out of time and gas, and it was time to land on our two good gear and right wing tank. We told tower we would try an arrested landing. We turned back around and set up for a low, long approach. Again, we came up with a game plan in case either of us felt things weren’t going right. If we boltered, we were going to take it around. I told Gary I wasn’t going to use the brake, just the nosewheel steering, because one wheel wouldn’t be turning, and the other one would. We briefly discussed taking the gear off-center to compensate for the extra drag on the right side, but we decided against adding another variable to our problem. Base reminded us to safe our seats before unstrapping—good idea.
The approach went smoothly, but I set down a little too far away from the A-gear, and couldn’t hold the right tank off the ground long enough. I used to believe when someone was telling me what they were thinking during an emergency or high-pressure situation, it was organized and orderly. I now know differently. As the tank began to skid on the runway, my reaction was, “Tank on ground, still controllable, gear’s up ahead, not good to drag tank across A-gear, get airborne!”
I got it back in the air before we got to the A-gear. We were at 850 pounds. I told tower and base what had happened, and we were going to try again.
On downwind, we decided if this attempt wasn’t successful, we’d run out of gas before we had a chance for another attempt. We probably would eject over water.
This time, as we rolled into the groove, I held a little more airspeed. We felt the hook start to drag about 1,200 feet from the gear. I kept up the power to keep the tank off the ground, and the left main touched down about 50 feet before the gear. When the hook grabbed the cable, I couldn’t hold the wing off the ground anymore, so we settled onto the left main, right tank, and
right front-nosegear. We slid toward the right side of the runway, but our jet still was controllable with the nosewheel.
After what seemed like an eternity, we finally came to rest about 20 feet from the runway edge and 40 feet from the grass. As I safed my seat, I said, “Safe in the front,” and could get back to them. They let us know when everything was prepared and waiting, and they didn’t clobber the radio with extra chatter.
Base also was extremely helpful, only giving us what we needed to know. Neither Gary nor I would have thought to safe our seats after we stopped. Base had sent an LSO out to the end of the runway for us, but he chose to keep himself out of the problem, which was the right thing to do. Gary and I had a plan each time we went around. We communicated that plan to tower and base, who let us execute without interjecting comm calls and unnecessary questions or info. In the end, the only damage the jet sustained was to the right external tank. The right aileron was only inches off the ground but never touched. I never again will complain about being double bubble. As we filled out our yellow sheet later that evening, I wrote a MAF, “Right main-landing tank worn beyond limits.”
Gary replied, “Safe in the rear.”
I pulled off the throttles, opened the canopy, pressed both fire lights, turned off the battery, unstrapped, and climbed out onto the left wing, jumped onto the left wing tank, and then to the ground, closely followed by Gary; both us were glad to have made it.
Many things could have gone wrong, but everything went right for us that day. Iwakuni tower did an outstanding job of alerting the crash crew and getting things prepared for us. If they asked us for something, and we told them to standby, they waited patiently until we
Capt. de Carion (pilot) and Capt. Matthew Desmond, USMC, (WSO) flew with VMFA (AW)-225.
This Hornet crew displayed sound crew-resource-management skills, not only in the aircraft but by using outside sources, as well. Several questions come to mind. How many times would you try to restart an engine? How many times should you? Is the jet trying to tell you something?
After the jet is on deck, the crew is safe (with a change of flight suits and underwear), and the sea story has been told and written, the job still is incomplete. Why did the engine not start? Why did the landing gear fail to extend? And finally, when those questions are answered, does the rest of the community know the reasons?—Capt. Ken Neubauer, Director, Aviation Safety Programs, Naval Safety Center.
From left to right: Maj. Sanjeev Shinde, Sgt. Darren Hitch, Sgt. Christopher Barrett, and Maj. Ethan Andrews.
Crosshair 61 was Dash 2 in a flight of three during a combat flight from a forward-operating base (FOB) in eastern Afghanistan to Bagram Airfield, Afghanistan.
It was just after sunset when the flight crew prepared to land at their destination after the two-hour flight. About three miles south of Bagram, the UH-1N suddenly developed a highfrequency airframe vibration. They needed to land as soon as possible, if not immediately. The vibration was severe, and the nature of the damage (e.g., mechanical failure or battle damage) was unknown.
Maj. Sanjeev Shinde, aircraft commander, set up to land at a clearing off the nose; the crew prepared to land. Maj. Shinde broadcast a Mayday call over the common air-toground frequency. While on final for landing, Maj. Ethan Andrews, copilot, with Sgt. Christopher Barrett and Sgt. Darren Hitch, crew chiefs, saw the landing zone was unsuitable because of deep ruts. Maj. Shinde continued for another 50 yards to a more suitable area and made a no-hover landing. The time from onset of the vibration to landing was less than one minute.
After landing, Maj. Shinde shut down the aircraft. Because of the uncertain tactical situation, Maj. Andrews and the crew quickly exited the aircraft and established a defensive perimeter. Dash 3, an AH-1W, took overhead cover, while the lead UH-1N continued to Bagram to facilitate the recovery effort.
During the landing, Sgts. Barrett and Hitch observed the tail rotor and 90-degree gearbox wobbling severely. With the pilots manning the defensive perimeter, the crew chiefs inspected the tail rotor. They found a large chunk of material missing from the end-cap portion of one blade. This missing material made the tail rotor extremely out-of-balance, which caused the vibration. This information was relayed to the squadron maintenance department. Within minutes, the lead UH-1N returned with a toolbox.
While the pilots continued to man defensive positions, the crew chiefs quickly removed the damaged tail-rotor blade. At Bagram, the squadron maintenance department rapidly organized the personnel, equipment and parts to make the recovery. In less than three hours, at night, in austere conditions, the squadron maintenance department changed the damaged tail rotor and returned the aircraft to Bagram.
This crew weighed the risks and correctly made the tough call: Land for an aircraft emergency, despite being over unsecured territory in a combat zone. Had they delayed their decision to land, this story could have been the background for an SIR, not a BZ. —Ed.
Schedule a safety culture workshop at: www.safetycenter.navy.mil/culture/request.htm
